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Simple Clinical Predictors May Obviate Urgent Endoscopy in Selected Patients With Nonvariceal Upper Gastrointestinal Tract Bleeding
Joseph Romagnuolo, MScEpid, MD, FRCPC;
Alan N. Barkun, MScEpid, MD, CM, FRCPC;
Robert Enns, MD, FRCPC;
David Armstrong, MD, FRCPC;
Jamie Gregor, MScEpid, MD, FRCPC; for the Registry for Upper GI Bleeding and Endoscopy Investigator Group
Arch Intern Med. 2007;167(3):265-270.
Background The validated Blatchford risk score (BRS) predicts outcomes in patients with nonvariceal upper gastrointestinal tract bleeding, before endoscopy; completion of the Rockall score requires endoscopy. The aims of this study were to predict whether the modified BRS (mBRS) can predict (1) endoscopic high-risk stigmata (HRS) and (2) rebleeding and mortality.
Methods Clinical and demographic characteristics on 1869 patients from 6 Canadian provinces were prospectively entered into the Registry for Upper GI Bleeding and Endoscopy database, recording 30-day rebleeding and mortality. The Rockall score and mBRS (hemoglobin level, hemodynamic instability, and presence of melena, liver disease, or cardiac failure; urea and syncope were not recorded) were calculated. Logistic regression was used to assess the association between an mBRS of 1 or less with HRS and with rebleeding and mortality.
Results The mean (SD) age of the patients was 66 (17) years, with 62% men and a mean of 2.5 comorbidities. Of the 1860 patients with 30-day rebleeding data, 334 (18.0%) rebled; 5.3% died. The mBRS was 0 in 3% and 1 or less in 9.8% of patients; HRS were seen in 31.0% of patients. An mBRS of 1 or less was associated with lower rebleeding (5% vs 19%; P<.001) and mortality (0.5% vs 5.8%; P=.003), and was significant in multivariate analysis for rebleeding (odds ratio, 0.24; 95% confidence interval, 0.12-0.48) and mortality (odds ratio, 0.12; 95% confidence interval, 0.02-0.90). The HRS were less frequent when the mBRS was 1 or less (16.9% vs 32.7%; odds ratio, 0.4; 95% confidence interval, 0.3-0.6). Patients with a low mBRS with HRS had a low rebleeding rate (3.3%) and a lower apparent benefit from endoscopic therapy.
Conclusions An mBRS of 1 or less identifies approximately 10% of patients with gastrointestinal tract bleeding with a low likelihood of having HRS and a low risk of adverse outcomes. A prospective randomized study is required to examine whether this subgroup of patients presenting after hours could be discharged safely from emergency departments with arrangements for (urgent) outpatient endoscopy.
Author Affiliations: Departments of Medicine and Biometry, Bioinformatics and Epidemiology, Medical University of South Carolina, Charleston (Dr Romagnuolo); Departments of Medicine (Drs Barkun, Enns, Armstrong, and Gregor) and Epidemiology and Biostatistics (Dr Barkun), McGill University, Montreal, Quebec; and Departments of Medicine, University of British Columbia, Vancouver (Dr Enns), McMaster University, Hamilton, Ontario (Dr Armstrong), and University of Western Ontario, London (Dr Gregor).
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